SITE DORMANCY DECLARATION FORM ALL SUBMISSIONS TO BE RECEIVED

SITE DORMANCY

DECLARATION FORM

All submissions to be received digitally via email to [email protected]

Date Received

ADMINISTRATIVE INFORMATION

A

Permit Holder:

Mailing Address:

City:

Province:

Postal Code:

Name:

Title/Position:

Phone Number:

Email Address:

SITE DORMANCY DECLARATIONS

B

The following sites are being declared as dormant under Section 3(1)(b) of the Dormancy & Shutdown Regulation. If additional space is required, you may submit an Excel spreadsheet with the same columns and headers as shown below along with this Site Dormancy Declaration Form.

WA Number

Wellsite Dormancy Date

Well Dormancy Type

(A, B, C)

FORM SUBMISSION DECLARATION

C

In completing this declaration form I_______________________________________________(Print Name) solemnly declare that the information provided above is true and that no relevant information has been omitted, I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same legal force and effect as if made under oath. I further declare that I am authorized to submit this form on behalf of the permit holder.

Submission Date (MM/DD/YYYY):

Signature: